Aims

The existing clinical guidelines do not describe a clear indication for adjuvant radiotherapy (RT) in the treatment of superficial soft tissue sarcomas (STSs). We aimed to determine the efficacy of adjuvant RT for superficial STSs.

Aim

We present the long-term surgical outcomes, complications, implant survival and causes of implant failure in patients treated with the modified Harrington procedure using antegrade large diameter pins.

Aims

The purpose of this study was to report the long-term results of extendable endoprostheses of the humerus in children after the resection of a bone sarcoma.

Aims

The aim of this study was to present the long-term surgical outcomes, complications, implant survival, and causes of implant failure in patients treated with the modified Harrington procedure using antegrade large diameter pins.

Aims

The purpose of this study was to review a large cohort of patients and further assess the correlation between the histological response to chemotherapy in patients with Ewing’s sarcoma with the overall (OS) and event-free survival (EFS).

Bone sarcomas are rare cancers and orthopaedic surgeons come across them infrequently, sometimes unexpectedly during surgical procedures. We investigated the outcomes of patients who underwent a surgical procedure where sarcomas were found unexpectedly and were subsequently referred to our unit for treatment. We identified 95 patients (44 intra-lesional excisions, 35 fracture fixations, 16 joint replacements) with mean age of 48 years (11 to 83); 60% were males (n = 57). Local recurrence arose in 40% who underwent limb salvage surgery versus 12% who had an amputation. Despite achieving local control, overall survival was worse for patients treated with amputation rather than limb salvage (54% vs 75% five-year survival). Factors that negatively influenced survival were invasive primary surgery (fracture fixation, joint replacement), a delay of greater than two months until referral to our oncology service, and high-grade tumours. Survival in these circumstances depends mostly on factors that are determined prior to definitive treatment by a tertiary orthopaedic oncology unit. Limb salvage in this group of patients is associated with a higher rate of inadequate marginal surgery and, consequently, higher local recurrence rates than amputation, but should still be attempted whenever possible, as local control is not the primary determinant of survival.

Cite this article: Bone Joint J 2014;96-B:665–72.

A clinical evaluation of the effect of MRI scan to bring about a change in surgical management of elderly patients who present with hip fracture with no history of trauma or a suspicious looking lesion on x-rays. Many of these patients present with or without history of previous malignancy or bone disorder.

We evaluated that if the delay in treatment within 36 hours as per national guide lines is justified to benefit patients.

Aim

To estimate the risk of bone malignancy arising in premalignant conditions.

Introduction

The aim of this study is to evaluate the functional and oncological outcome of extracorporeally irradiated autografts as a method of pelvic reconstruction after internal hemipelvectomy.

Osteosarcomas represent a heterogeneous group of primary bone tumours that affect predominantly the long bones of patients in the first two decades of life. We aim to describe the secondary effects of a poor response (⋋90% necrosis) to chemotherapy on the effectivity of other treatment outcomes, local recurrence and survival rates.

182 cases of osteosarcoma with necrosis of less than 90% and no metastases at diagnosis have been seen at our institution over 24 years. There were 60 amputations. 122 patients underwent limb salvage, with 105 marginal margins and 17 contaminated. There was no difference in size or location between the two groups. In the 122 patients with LSS, 21 had adjuvant radiotherapy and 101 did not. In the entirety of patients with ⋋90% necrosis, survival was 64% at 2 years and 37% at 5 years. When LSS Marginal resections were compared with amputation there was a significant (P=0.006) difference in survival. LSS with a marginal margin had a 25% risk of LR. In these patients there was 25% survival, whereas the absence of a local recurrence, conferred a benefit of a 40% survival XRT was used in 21 of the 122 who underwent limb salvage. The decision to use XRT was made by the local oncologist at the treating unit. There was a 24% rate of recurrence in the XRT group and 25% with no XRT.

These data demonstrated that patients who had a poor response to chemotherapy and underwent an amputation faired poorly when compared to patients with LSS. There is a selection bias in patients selected to undergo amputation. Additionally, patients who underwent amputation had a lower rate of local recurrence, but still had a poorer survival when compared to LSS.

Introduction

The role of adjuvants in curettage for giant cell tumours (GCT) is still controversial. Our aim was to determine if adjuvant cementation lowers local recurrence (LR) rates for GCTs treated with curettage.

Aim

To investigate the effectiveness of silver coated prostheses in preventing periprosthetic infection in a high-risk group.

Introduction

Myxofibrosarcoma is described by WHO as comprising of a spectrum of malignant fibroblastic lesions with variably myxoid stoma, pleomorphism and with a distinctively curvilinear vascular pattern. They are reported to be one of the commonest sarcomas of elderly patients. It has previously been reported to have a high rate of locally recurrent disease (50-60%). The aim of the study was to investigate the ROH series of tumours to determine prognostic factors for survival and local recurrence.

The aim was to identify when primary amputation was used as primary treatment and to describe outcomes in patients managed with modern chemotherapy. A detailed review of the electronic patient records was undertaken. Statistical analysis was performed with univariate analysis using Kaplan-Meier curves and Chi² testing, whilst multivariate analysis was performed using Cox regression analysis.

There were 354 osteosarcomas. 93 patients presented with metastases and 192 subsequently developed metastases at a mean of 46 months. Amputation was performed as the primary surgical treatment in 101 patients. Endoprosthetic reconstruction was used in 253 patients. Amputation was performed as a secondary procedure on 15 patients.

The 5 and 10 year survival data for all patients, including those with metastatic disease were 60% and 60% for amputation with good chemotherapy response (>89% necrosis), 65% and 63% for limb salvage and good response, 21% and 21% for amputation and poor response (⋋90% necrosis) and 51% and 30% for limb salvage with poor response.

Local recurrence occurred both with amputation (10.8%) or limb salvage (9%), with no significant differences between the two.

Univariate analysis demonstrated that the extent of response to chemotherapy induced necrosis significantly affected survival, whether the patient had an amputation or not.

Whether or not amputation or LSS was used in the surgical management of patients, local recurrence rates where similar between the two groups. Further assessment of chemotherapy-induced necrosis is a key factor in determining subsequent limb salvage or amputation management strategies.

Chondrosarcoma of bone is a surgical disease and excision with wide margins is the optimum treatment. Sometimes the size or location of the tumour at the time of diagnosis mean that only a marginal excision can be achieved. The effect of the margin of excision on outcome is investigated.

Non-invasive expandable prostheses for limb salvage tumour surgery were first used in 2002. These implants allow ongoing lengthening of the operated limb to maintain limb-length equality and function while avoiding unnecessary repeat surgeries and the phenomenon of anniversary operations.

A large series of skeletally immature patients have been treated with these implants at the two leading orthopaedic oncology centres in England (Royal National Orthopaedic Hospital, Stanmore, and Royal Orthopaedic Hospital, Birmingham).

An up to date review of these patients has been made, documenting the relevant diagnoses, sites of tumour and types of implant used. 87 patients were assessed, with an age range of 5 to 17 years and follow up range of up to 88 months.

Primary diagnosis was osteosarcoma, followed by Ewing's sarcoma. We implanted distal femoral, proximal femoral, total femoral and proximal tibial prostheses. All implants involving the knee joint used a rotating hinge knee. 6 implants reached maximum length and were revised. 8 implants had issues with lengthening but only 4 of these were identified as being due to failure of the lengthening mechanism and were revised successfully. Deep infection was limited to 5% of patients.

Overall satisfaction was high with the patients avoiding operative lengthening and tolerating the non-invasive lengthenings well. Combined with satisfactory survivorship and functional outcome, we commend its use in the immature population of long bone tumour cases.

Aim

To identify factors leading to the success or failure of extracorporeal irradiation and re-implantation of bone (ECIR).

Aim

To determine the overall survival of patients with Pelvic Ewing's Sarcoma treated in our unit and to identify prognostic factors in pelvic primaries that could be used to select patients who would most likely benefit from high intensity treatment.

Introduction

The aim of this study was to investigate the results of a series of cases from a single institution with respect to local disease control and patient survival to determine prognostic factors.

Since1986 we have monitored the actual diagnosis of all cases referred to our Unit with the diagnosis of ‘possible primary malignant bone tumour’. We have excluded all patients referred with a known diagnosis of either a benign condition or known to have bone metastases. In most cases the suspected diagnosis was based on X-rays alone, sometimes supported by further imaging.

Neoadjuvant chemotherapy for osteosarcoma improves outcomes for the majority, but if the chemotherapy does not work then the dilemma often arises as to whether to do limb salvage with a marginal (or worse) margin of excision or to do an amputation. If limb salvage is carried out with a close margin, does post operative radiotherapy make any difference? This study aims to address these questions.

The outcome for patients with Ewing's sarcoma recurrence is poor. Local recurrences occur in 8%-25%of these patients. The aim of the study was to analyze the patients who had a local recurrence to identify factors predicting the local recurrence and if it could be prevented

Introduction

The pelvis has always been a difficult area for surgeons, with high complication rates from surgery and the perception of poor oncological outcomes. The aim of the study was to look at the surgical and oncological outcomes of pelvic tumours treated at our centre.

Solitary plasmacytomas in the appendicular skeleton are rare monoclonal expansions of plasmacytoid cells. They are two main hazards; local destruction of bone with resultant loss of function and possible fracture, and progression to Myeloma.

Between February 1988 and July 2005 seven patients (4 male, 3 female) were treated for solitary plasmacytoma with surgical resection and endoprosthetic reconstruction. The median age was 46.7 (35-75). The site was: distal humerus (2), proximal humerus (2) proximal femur (2) proximal tibia (1). Three patients had sustained a pathological fracture. Five patients had received pre-operative radiotherapy and three received post-operative radiotherapy. Mean follow-up is 8.6 years. Two cases became infected at 2 and 5 years post-operatively and have had revisions of their endoprosthesis. Both remain functional at 18 and 15 years. No patient has suffered a local recurrence. Two patients have progressed to multiple Myeloma but no patients have died. Literature review shows that the progression of solitary bone plasmacytoma to Myeloma is around 53% despite radiotherapy, in an average period of 2-4 years. With resection and endoprosthetic reconstruction, the progression in this series has been 28% despite an average follow up of 8.6 years.

Although the numbers are small, due to the rarity of the condition, surgical resection and endoprosthetic reconstruction reduces disease progression than radiotherapy alone. This produces far superior results compared to the intramedullary nailing of the long bones for this condition. Endoprosthetic reconstruction after resection should be given consideration in cases of solitary plasmacytoma of the appendicular skeleton when there is extensive bone destruction present. The optimal timing of local radiotherapy to be combined with surgery is still to be established.

Between 1966 and 2001, 1254 patients underwent excision of a bone tumour with endoprosthetic replacement. All patients who had radiotherapy were identified. Their clinical details were retrieved from their records.

A total of 63 patients (5%) had received adjunctive radiotherapy, 29 pre-operatively and 34 post-operatively. The mean post-operative Musculoskeletal Tumor Society scores of irradiated patients were significantly lower (log-rank test, p = 0.009). The infection rate in the group who had not been irradiated was 9.8% (117 of 1191), compared with 20.7% (6 of 29) in those who had pre-operative radiotherapy and 35.3% (12 of 34) in those who radiotherapy post-operatively. The infection-free survival rate at ten years was 85.5% for patients without radiotherapy, 74.1% for those who had pre-operative radiotherapy and 44.8% for those who had post-operative radiotherapy (log-rank test, p < 0.001). The ten-year limb salvage rate was 89% for those who did not have radiotherapy and 76% for those who did (log-rank test, p = 0.02).

Radiotherapy increased the risk of revision (log-rank test, p = 0.015). A total of ten amputations were necessary to control infection, of which nine were successful. Radiotherapy may be necessary for the treatment of a bone sarcoma but increases the risk of deep infection for which amputation may be the only solution.

We have investigated whether improvements in design have altered the outcome for patients undergoing endoprosthetic replacement of the distal femur following tumour resection.

Survival of the implant and ‘servicing’ procedures have been documented using a prospective database and review of the implant design records and case records. A total of 335 patients underwent a distal femoral replacement with 162 having a fixed hinge design and 173 a rotating hinge with most of the latter group having a hydroxyapatite collar at the bone prosthesis junction. The median age of the patients was 24 years (range 13-82 yrs). With a minimum follow up of 5 years and a maximum of 30 years, 192 patients remain alive with a median follow-up of 11 years. The risk of revision for any reason was 17% at 5 years, 34% at 10 years and 58% at 20 years. One in ten patients developed an infection and 42% of these patients eventually required an amputation. Aseptic loosening was the most common reason for revision in the fixed hinge knees whilst infection and stem fracture were the most common reason in the rotating hinges. The risk of revision for aseptic loosening in the fixed hinges was 32% at ten years compared with nil for the rotating hinge knees with a hydroxyapatite collar. The overall risk of revision for any reason was halved by use of the rotating hinge, and for patients older than 40 years at time of implant.

EPRs are the treatment of choice following resection of tumours. These have been used for 39 years in our institution. There has been concern regarding the long term survival of endoprosthesis; this study investigates the fate of the reconstruction.

Chondroblastomas arise in the epiphyseal area of bones. In the femoral head this can cause considerable difficulty in obtaining access as the epiphysis is entirely intra-articular.

We have reviewed management and outcome of 10 patients with chondroblastoma of the femoral head to identify outcome and complications. The mean age was 14 years and all presented with pain (frequently in the knee) and a limp. All were diagnosed on plain Xray and MRI. Five younger children were treated by curettage by a lateral approach up the femoral neck (to try and minimise damage to the epiphysis) and five by a direct approach through the joint.

Two of the five patients with a lateral approach developed local recurrence whilst none of the direct approaches did. Both local recurrences were cured with a direct curettage. One patient developed overlengthening of the leg by 1cm but there was no case of growth arrest or osteoarthritis.

We recommend a direct approach to the lesion whenever possible to give the best chance of cure with a low risk of complications.

Introduction

Despite the advances in adjuvant chemotherapy and surgical techniques, the diagnosis of a bone tumour still carries with it a significant risk of mortality. This study investigates factors affecting survival, in patients treated for malignant tumours of bone using Endoprosthetic replacement (EPR).

Aim

To identify patient, tumour or treatment factors that influence outcome in patients with radiation induced sarcoma of bone.

Primary malignant bone tumours frequently arise in children close to the knee, hip or shoulder. Resection of the tumour will often require excision of the epiphysis and frequently one side of the involved joint. In these children an extendable endoprosthesis is usually required to allow for maintenance of limb length equality.

We have used 180 extendable endoprostheses in 176 children since 1975. The indication for use of an extendable prosthesis was if there was more than 30mm of growth remaining in the resected bone. The age of the patients ranged from 2 to 15 and 99 were boys. The sites of the endoprostheses used were: distal femur in 91, proximal tibia in 42, proximal femur in 11, total femur in 6 and proximal or total humerus in 26. 131 of the operations were for osteosarcoma and 34 for Ewing's.

Five types of lengthening mechanism have been used. Two designs used a worm screw gear, one type used a C collar, one type a ball bearing mechanism and the latest uses a non invasive lengthening system whereby a motor inside the prosthesis is activated by an electromagnetic field.

Of the 176 patients, 59 have died and of the remainder, 89 have reached skeletal maturity. 19 patients had an amputation, 11 due to local recurrence and 8 due to infection. The risk of infection was 19% in surviving patients. Most of the skeletally mature had equal leg lengths. The average number of operations was 11 but ranged between 2 and 29. Most operations were for lengthening but younger children always needed revisions of the prosthesis. Functional scores were 77%.

Extendable endoprostheses are demanding both for the patient and the surgeon. The high complication rate should be decreased by non invasive lengthening prostheses.

All patients referred to our unit with previously untreated metastatic renal cancer were included in this review. We investigated likely prognostic factors including age, sex, site, synchronous or metachronous metastasis, stage of the disease and the type of treatment received.

From 1976 until 2004, a total of 198 patients were treated by our unit for renal metastases. 15 patients were excluded because they were referred after failure of previous treatment or only had advice. 96 patients were already known to have renal metastasis with their diagnosis having been made between 0.2 and 17 years from the diagnosis of primary cancer (mean 4 years). 33 patients presented to us with a pathological fracture and were found to have renal cancer. A total of 54 patients had multiple metastases and 129 had a solitary metastasis. The cumulative survival from the time of diagnosis of the bone metastasis is 70 percent at 1 year, 40% at 3 years and 18% at 5 years. In patients with a solitary metastasis, the overall survival was 74% at 1 year and 45% at 3 years, whereas in patients with multiple metastases it was 55% at 1 year and 22% at 3 years. (p=0.02) In patients with a solitary metastasis treated by excision of the metastasis, the survival at 1 year was 86% as compared to 38% for those that were treated with just a local procedure. Cox multivariate analysis shows that survival was better in those with solitary metachronus metastasis who underwent a radical procedure.

Background: Malignant tumours of the radius compose only 3% of all upper limb tumours. Owing to their rarity they are often difficult to manage satisfactorily. Of the options for fixation available, endo-prosthetic replacements have been scarcely utilized despite their success in limb preservation with malignant tumours in other parts of the body. At our centre we have used these when biological solutions (eg fibula graft) were not indicated due to extensive disease or the need for radiotherapy.

Patients: We performed four endoprosthetic replacements of the distal radius in three males and one female with ages ranging from 19–66 years (average= 42.25 years of age). Two were performed for varieties of osteosarcoma (parosteal and osteoblastic osteosarcomas), one for a large destructive giant cell tumour (GCT) and one for destructive renal metastases. Three were right sided (75%) and one left sided (25%).

Methods: Medical records were evaluated for information on local recurrence, metastases, complications and functional outcome using the Toronto Extremity Salvage Score (TESS).

Results: Follow up ranged from 22 to 205 months (average= 116.5 months). The average TESS score was 58.1% (range= 44.6–74.5%). Neither case of osteosarcoma recurred. The GCT recurred twice and the patient with renal metastases had nodules removed from his affected wrist on two further occasions. There were no cases of infection, but one of the earlier cases had problems with metacarpal stems cutting out and joint subluxation. The two earlier cases have since died at 205 (parosteal osteosarcoma) and 189 months (GCT) respectively of other disease.

Conclusions: We conclude that although this is a very small series of endoprosthetic replacement of the distal radius, the technique is a useful addition to the surgical options, with acceptable post-operative functional results and complication rates when a biological solution or preservation of the wrist joint is not indicated.

Non-invasive expandable prostheses for limb salvage tumour surgery were first used in 2002. These implants allow ongoing lengthening of the operated limb to maintain limb-length equality and function while avoiding unnecessary repeat surgeries and the phenomenon of anniversary operations.

A large series of skeletally immature patients have been treated with these implants at the two leading orthopaedic oncology centres in England (Royal National Orthopaedic Hospital, Stanmore, and Royal Orthopaedic Hospital, Birmingham).

An up to date review of these patients has been made, documenting the relevant diagnoses, sites of tumour and types of implant used. 74 patients were assessed, with an age range of 7 – 16 years and follow up range of 4 – 88 months.

We identified five problems with lengthening. One was due to soft tissue restriction which resolved following excision of the hindering tissue. Another was due to autoclaving of the prosthesis prior to insertion and this patient, along with two others, all had successful further surgery to replace the gearbox. Another six patients required mechanism revision when the prosthesis had reached its maximal length. Complications included one fracture of the prosthesis that was revised successfully and six cases of metalwork infection (two of which were present prior to insertion of the implant and three of which were treated successfully with silver-coated implants). There were no cases of aseptic loosening.

Overall satisfaction was high with the patients avoiding operative lengthening and tolerating the non-invasive lengthenings well. Combined with satisfactory survivorship and functional outcome, we commend its use in the immature population of long bone tumour cases.

Introduction: Giant cell tumor (GCT) is a benign but locally aggressive tumor that primarily affects the epiphyses of long bones of young adults. Pulmonary metastases in giant cell tumor are rare. We report our experience of treating pulmonary metastatic GCT of bone over the last 24 years between 1984–2007.

Methods: A retrospective review of patients’ records and oncology database of patients with metastatic GCT

Results: We had 471 patients with GCT of bone out of which 7 patients developed pulmonary metastases (1.48%). Six patients following diagnosis and initial treatment and one with pulmonary metastases present at the diagnosis. There were 4 males and 3 females aged between 23 to 40 years (median, 27 years). All patients had GCT around the knee (distal femur/proximal tibia). All patients eventually required Endoprosthetic Replacement apart from one who was treated with curettage only. The time of pulmonary metastases from initial diagnosis was 16–92 months (median, 44.6 months). All patients who developed metastases in the postoperative period had thoracotomy for excision of the pulmonary metastases. Two patients received chemotherapy for control of the local recurrence. At an average follow up of 151 months (27–304 months), all patients were alive

Discussion: Pulmonary metastases have been reported as 1% to 9% in GCT. Because of its rarity, very little is known about the long-term outcome and the best treatment for the pulmonary lesions. The mortality rates recorded for patients with pulmonary metastatic GCT range from 0% to 37%. In our series the mortality rate was 0% and metastases 1.48%. It seems that surgical resection of pulmonary metastases gave excellent rate of survival.

Aim: To identify factors leading to the success or failure of extracorporeal irradiation and reimplantation of bone (ECIR).

Method: Review of experience of this technique since 1996 documenting successes and failures.

Results: 35 patients with a variety of malignant bone tumours underwent ECIR from 1996 up to 2007. The most common diagnosis was Ewings’ sarcoma (15) followed by osteosarcoma (9) and chondrosarcoma (5) with the most common sites being the pelvis (15) followed by the tibia (10) and humerus (3). The age range was from 7 to 66 and 8 were skeletally immature at the time of surgery. The bones were sterilised with a dose of 90Gy before reimplantation.

The overall patient survival was 69% at 5 years and 62% at 10 years. Local recurrence arose in 4 cases, 3 of whom already had metastatic disease. None of the LR arose in the irradiated bone. The rate of non union was 9% at the 58 osteotomies, the greatest risk being in the tibia. There were four graft fractures of which 3 needed fixation and all united. There is one case of convincing graft resorbtion after 12 years. Two patients developed infections but there have been none since the done was routinely immersed in antibiotics whilst being irradiated.

Conclusion: ECIR is a useful technique with very limited indications. In the majority of cases it works well. It appears particularly useful in pelvic resections and diaphyseal resections. Distal tibial reconstructions do worst. The irradiated bone needs reinforcing with either cement or a bone graft for best results.

The purpose of our study was to examine the survival and functional outcome of endoprosthetic replacements for non-oncology limb salvage purposes. Although initially designed for bone tumours, such is the versatility of these implants they can be used to salvage failed joint replacements, peri-prosthetic fractures, failed internal fixation and non-union.

Thirty eight procedures were identified from September 1995 to June 2007 from a prospectively kept database, including 17 distal femoral replacements, 12 proximal femoral replacements, 4 proximal humeral replacements, 2 distal humeral replacements, 2 hemi-pelvic replacements and 1 total femoral replacement. The quality of patients’ mobility was used to assess functional outcome and the survival of the prosthesis was calculated using a Kaplan-Meier survival curve.

The Kaplan-Meier implant survival was 91.3% at 5 years, 68.5% at 10 years and 45.7% at 20 years. The limb salvage survival for all reconstructions was 75% at 10 years.

The best survival was as follows pelvic (n=0/2) and total femoral prostheses where there was no failure in either group (n=0/1). Distal femoral replacements survival was 91% at 5 years, a single humeral prosthesis failed at 11 years post surgery, and proximal femoral replacements had a survival at 87.5% at 5 years. Three implants failed, two as a result of infection and required staged revisions and 1 failed as a result of aseptic loosening. Two patients dislocated their proximal femoral replacements, both were treated successfully by closed reduction.

Endoprosthetic replacement appears to be effective and the medium term survival is encouraging. The aim of a pain free functional limb is achievable with this technique. The complication rates are acceptable considering the salvage nature of these patients. We recommend referral of complex cases to a tertiary centre with expertise in this type of surgery.

Patients who undergo soft tissue sarcoma excision accumulate serosanguinous fluid, potentially resulting in a seroma. This can lead to wound complications and delay post-op radiotherapy.

The purpose of this preliminary report is to assess the impact of routine application of Tisseel sealant prior to closure.

We investigated whether the sealant Tisseel is effective as a sealing agent to reduce the duration and volume of serosanguinous fluid drainage. Results were compared with individually matched controls.

Patients were split into 2 groups: those receiving 10mls sealant and those not receiving the sealant. Efficacy was evaluated by the number of days required for wound drainage, the volume of fluid drainage and the length of stay compared with matched controls.

The preliminary findings suggest that application of the sealant reduced the duration and quantity of fluid drainage after excision of the STS, allowing earlier discharge from hospital.

We present this work to suggest that the members of the British Orthopaedic Oncology Society should consider using this in a randomised controlled trial setting to evaluate its efficacy nationally.

Chondrosarcoma is treated with respect by oncology surgeons, given that it is relatively resistant to chemotherapy and radiotherapy. The aim was to study the outcomes of surgery for chondrosarcoma and determine the role of initial surgical margins and local recurrence on outcome.

Electronic patient records were retrieved on all patients seen with chondrosarcoma of bone with a minimum of two years follow up. A total of 532 patients were seen with Chondrosarcoma between 1970 and 2006. Patients were excluded if they had initial treatment in another unit (20 patients), a subdiagnosis of dedifferentiated chondrosarcoma (due to very poor prognosis, 43 patients), metastases at presentation (30 patients), if they presented with disseminated metastases prior to local recurrence (12 patients) or were not offered surgery, leaving 402 patients in the study group.

The mean age was 48 years old (range 6–89 years) with the most commonly sites of presentation being in the pelvis in 132 patients (29%), proximal femur in 81 patients (18%), distal femur in 40 patients (9%) and proximal humerus in 40 patients (9%). Grade at presentation was grade 1 in 44%, grade 2 in 44% and grade 3 in 12%. Surgical margins were radical in 3%, wide in 44%, marginal in 29%, planned incisional in 13% and unplanned incisional in 11%. Local recurrence occurred in 87 patients (22%). Local recurrence rates were significantly different for surgical margins on Fisher exact testing (p=0.003), which held true even when stratified by presenting grade of tumour. Surgery for local control was successful in 62% of cases.

Complex relationships exist between surgical margins, local recurrence and survival. Long term survival is possible in 1/3 patients who have local recurrence in intermediate and high grade chondrosarcomas and therefore ever effort should be made to regain local control following local recurrence.

We have compared the cost:benefit ratio of the new type of non invasive extendable prostheses with the old type which required lengthening under general anaesthetic with an invasive procedure.

Over the past four years we have inserted 27 non invasive endoprostheses (cost £14,000). Two have failed to lengthen due to problems with the inbuilt motor. So far there have been no infections, no loosenings and no patient has required revision. The lengthenings are painless and take half an hour. In the past 25 years we inserted 175 extendable endoprostheses (cost £7,000). All lengthenings were performed under a general anaesthetic. The risk of infection was initially 20% at ten years but had decreased to 8%. Pain and stiffness arose in about 10% requiring physiotherapy or occasionally manipulation under anaesthetic.

Assuming the following costs (current NHS cost) are accurate and appropriate, then the non invasive extendable prosthesis becomes cost effective when Cost EPR < Cost old EPR + (Additional risk physio(P) x cost) + (additional cost x number of lengthenings (L)) + (additional cost of revision for infection x risk of infection (R)). 14000 < 7000 + (300 x P) + (1500 x L) + (20000 x R). Assuming a 10% need for physiotherapy, four lengthenings and a 10% risk of infection gives: 14000 < 7000 + (30) +(6000) + (2000) = 15030.

Given the high complication rate of the old type of extendable procedure and assuming there are few if any with the non invasive type, then the non-invasive endoprostheses becomes cost effective if more than three lengthenings are required. They are certainly more popular with parents and children alike!

Pelvic reconstruction after tumour resection is challenging. Pelvic replacements are usually custom made at considerable expense and then need very careful positioning at the time of surgery. They have a very high rate of complications with up to 30% risk of infection and 10% dislocation. In 2003 we developed a new type of pelvic replacement which would be simple to make, simple to use and which would hopefully avoid the major complications of previous pelvic replacements whist being versatile to use even when there was very little pelvis remaining. The concept is based on the old design of Ring stemmed hip replacement and has become known as the ice-cream cone prosthesis. It is inserted into the remnant of pelvis or sacrum and is surrounded by bone cement containing antibiotics. One of the main advantages is it’s flexibility, allowing insertion after resection at a variety of levels. It is also suitable for patients with metastatic disease.

We have inserted 12 of these implants in the past 4 years, resolving very difficult reconstruction problems. There was one case that became infected but was cured with washout and antibiotics. In one patient there was excessive leg lengthening resulting in a sciatic and femoral nerve palsy and the prosthesis had to be revised. All patients can walk with one stick or less.

These results are encouraging and suggest that this versatile implant may be the way forward for pelvic reconstruction because of it’s flexibility of use and low complication rate.

Aim: To review our experience of managing patients with aneurysmal bone cysts (ABCs).

Method: We reviewed the medical records and radiographs of all patients with ABCs treated at our unit over a 25 year period. During that time the policy of the unit was to treat ABCs with biopsy/curettage without use of adjuvants or bone grafting. Patients were followed up with regular Xrays until healing had taken place. Local recurrences were again treated with curettage, occasionally supplemented with embolisation or bone grafting.

Results: 237 patients (128 female, 109 male), with a median age of 14 yrs (range 1 to 76), received treatment. The cyst size varied from 1 to 20 cm and the median duration of symptoms was 16 weeks (range 0 to 8 yrs). The most common sites were the tibia (55), followed by the femur (41), then the pelvis (29) and the humerus (27). Thirty-five (15%) of the patients presented with a pathological fracture.

Primary treatment was by curettage alone in 195, curettage and bone grafting in 7, aspiration and injection of steroids or bone marrow in 7, excision in 5 and observation alone in 17. The rate of local recurrence requiring further surgery was 12% with all local recurrences (but one) arising within 18 months. Local recurrence was not related to site, age, sex or whether the patient had previous treatment or not. Local recurrences were managed with curettage alone in 19 of the 23 cases, with one having embolisation, one excision and 2 curettage and bone grafting. This was successful in all but 3 cases who were controlled with a third procedure.

Conclusion: The local control rate of ABCs with simple curettage is 88%, which is as good as the results published for any other technique. We recommend biopsy in all cases with limited curettage at the same time, and many ABCs will heal with this simple procedure. Full curettage is needed for those showing no signs of healing within 4 weeks. Local recurrence is very unusual after 18 months.

Of 3000 patients diagnosed with primary malignant bone tumours and treated at our unit over the past 25 years, 234 (7.8%) were considered to be spindle cell sarcomas of bone (ie not osteosarcoma, chondrosarcoma, Ewing’s, chordoma or adamantinoma). We have analyzed their management and outcomes.

The diagnosis of these cases varied with fluctuations in the popularity of conditions such as MFH, fibrosarcoma and leiomyosarcoma with the passage of time. Treatment was with chemotherapy and surgery whenever possible. 36 patients had metastases at diagnosis and 17 had palliative treatment only because of age or infirmity. The most common site was the femur followed by the tibia, pelvis and humerus. The mean age was 45 and the mean tumour size 10.2cm at diagnosis. 25% of patients presented with a pathological fracture. Chemotherapy was used in 70% of patients the most common regime being cisplatin and doxorubicin. 35% of patients having neoadjuvant chemotherapy had a good (> 90% necrosis) response. The amputation rate was 22% and was higher in patients presenting with a fracture and in older patients not having chemotherapy.

With a mean follow up of 8 years the overall survival was 64% at 5 yrs and 58% at 10 yrs. Adverse prognostic factors included the need for amputation, older age and poor response to chemotherapy as well as a pathological fracture at presentation. The few patients with angiosarcoma fared badly but there was no difference in outcomes between patients with other diagnoses.

We conclude that patients with spindle cell sarcomas should be treated similarly to patients with osteosarcoma and can expect comparable outcomes. The histological diagnosis does not appear to predict behaviour.

Low grade central osteosarcoma is a rare intramedullary bone producing tumour. It accounts for only 1–2% of all osteosarcomas. Due to the indolent nature of low grade central osteosarcoma, achieving a correct and prompt diagnosis is the real challenge both from imaging and histology, particularly as it may resemble a benign condition, i.e. Fibrous Dysplasia.

We have reviewed 15 cases of low grade central osteosarcoma with long term follow-up (2 to 22 years) to identify problems in diagnosis and treatment and to assess outcome.

There were 7 females and 8 males with a mean age of 37 yrs (range 11 to 72 years); 13 cases arose in the lower limb (8 femur, 4 tibia, 1 os calcis), 1 in the pelvis and 1 in the upper limb. The average duration of symptoms prior to presentation was over 2yrs. A primary diagnosis of low grade central osteosarcoma was achieved for only 6 cases (4 open and 2 needle biopsies), in the other 9 the primary diagnoses were GCT, cystic lesion or fibrous lesion (both benign and malignant) and all of them had undergone treatment (usually curettage with or without bone grafting for this). Definitive treatment was with surgery attempting to obtain wide margins. Marginal excision was associated with local recurrence in three cases but there were no local recurrences in patients who had a wide excision, even in those with prior treatment. Only one patient has died following the development of multiple metastases after 9 years. The survival rate is 90% at 15 years.

We present this study to show the difficulties in diagnosing this rare type of osteosarcoma and to highlight the importance of wide surgical margins to obtain local control.

Aim: To investigate the effectiveness of silver coated titanium prostheses in preventing periprosthetic infection in a group of very high risk patients.

Methods: Periprosthetic infection is one of the main problems in limb salvage surgery, especially for tibial and pelvic prostheses or following revision surgery, particularly if it has been done for a previous infection. We have used silver coated prostheses in 21 cases on a named patient basis and have now assessed the results.

Results: Between July 2006 and June 2008 21 patients had a silver coated prosthesis inserted. 11 patients were having a second stage revision after a previous infection, 6 were having a pelvic prosthesis inserted, 3 were having a primary tibial replacement and one a one stage proximal tibial revision. Three patients developed a postoperative infection, two of the pelvic replacements and one infected revision (a total femur replacement). Of these only one patient required removal of the prosthesis (for overwhelming coliform infection in a pelvic replacement) whilst the other two infections both settled with antibiotics and washout.

Discussion: The anticipated risk of infection in this high risk group would have been around 20%. The actual infection rate was 14% but two of the infections completely resolved with relatively modest treatment. This suggests that the silver coating may not only have a role in preventing infection but also enhancing control of infection should it arise. There were no other side effects and we believe that these preliminary results are encouraging and should lead to a further evaluation of silver for preventing infection around prostheses.

Disappearing bone disease is also known as vanishing bone disease, phantom bone disease, massive osteolysis, Gorham’s disease or Gorham-Stout disease. Basically, it is characterised by osteolysis in (contiguous) bone segments, due to localised proliferation of thin-walled vascular channels in the bone and surrounding soft tissues.

The etiology and pathophysiology of this condition remain poorly understood and largely unclear, but there is increasing evidence that disordered lymphangiogenesis plays a role. It is an extremely rare cause of osteolysis, so all other differential diagnoses should be considered and ruled out before retaining the diagnosis of disappearing bone disease.

Treatment is fairly disappointing and no single treatment modality has proven effective in actually arresting the disease. Conservative treatment includes ant-resorptive agents (bisphosphonates), immunomodulating substances and radiation therapy, whereas surgical treatment options include resection and reconstruction with bone grafts and/or prostheses versus amputation.

We report on the only two cases that were identified in our database between 1984 and 2008, both affecting the lower limb (one tibia, one femur). In an attempt to limb salvage, these patients initially underwent endoprosthetic replacement of the affected bone segment, but due to disease progression both eventually ended up with a hip disarticulation.

Conclusion: Although benign, this condition can be very aggressive, necessitating amputation to achieve local control.

Aim: To estimate the risk of bone malignancy arising in premalignant conditions.

Methods: There are quite a number of possible premalignant conditions with considerable uncertainty about the actual risk of a bone sarcoma developing. The incidence of these malignant conditions was identified from a prospective database containing 3000 primary bone sarcomas.

Results: 178 of the 3000 patients with newly diagnosed bone sarcomas had a pre-exiting condition which in all probability led to the sarcoma. These included 50 with previous radiotherapy treatment and 47 with Paget’s disease. 31 patients developed malignancy in HME, 8 with neurofibromatosis and 7 each with Ollier’s disease and retinoblastoma. There were 4 malignancies in patients with Mafucci’s syndrome, 3 in patients with fibrous dysplasia, 3 in patients with synovial chondromatosis and 2 in patients with Rothmund-Thomson syndrome.

Given that the incidence of bone sarcomas is 9/million population per year, our 3000 patients represent 333 million population years. When the incidence of a condition is known in the population this allows an estimation of the risk of malignancy compared with the normal population. Retinoblastoma for instance is known to arise in 1 in 16000 births. The 7 malignancies we saw thus represents a risk to individuals with retinoblastoma of 336/million/yr – a figure 37 times the risk of the normal population. Approximate figures of risk have been calculated for other entities.

Conclusion: Data from a supra-regional register allows an approximate estimate of the increased risk of bone tumours in premalignant conditions.

Malignant tumours of the radius compose only 3% of all upper limb tumours. Owing to their rarity they are often difficult to manage satisfactorily. Of the options for fixation available, endoprosthetic replacements have been scarcely utilized despite their success in limb preservation with malignant tumours in other parts of the body. At our centre we have used these when biological solutions (eg fibula graft) were not indicated due to extensive disease or the need for radiotherapy.

We performed four endoprosthetic replacements of the distal radius in three males and one female with ages ranging from 19–66 years (average= 42.25 years of age). Two were performed for varieties of osteosarcoma (parosteal and osteoblastic osteosarcomas), one for a large destructive giant cell tumour (GCT) and one for destructive renal metastases. Three were right sided (75%) and one left sided (25%).

Medical records were evaluated for information on local recurrence, metastases, complications and functional outcome using the Toronto Extremity Salvage Score (TESS). Follow up ranged from 22 to 205 months (average= 116.5 months). The average TESS score was 58.1% (range= 44.6–74.5%). Neither case of osteosarcoma recurred. The GCT recurred twice and the patient with renal metastases had nodules removed from his affected wrist on two further occasions. There were no cases of infection, but the two earlier cases had problems with metacarpal stems cutting out and jointsubluxatinos. The two earlier cases have since died at 205 (parosteal osteosarcoma) and 189 months (GCT) respectively of other disease.

We conclude that although this is a very small series of endoprosthetic replacement of the distal radius, the technique is a useful addition to the surgical options, with acceptable postoperative functional results and complication rates when a biological solution or preservation of the wrist joint is not indicated.

Introduction: Limb salvage reconstruction evolved from the treatment of primary bone tumours. Endoprosthetic replacements (EPR) were originally designed for this purpose, but the versatility of these implants has resulted in an extension in the indications for their use. Severe bone loss, failed revision surgery and persistent deep infection present similar challenges and when a salvage procedure is required, EPR are occasionally used. The aim of our study was to assess the medium term survival and functional outcome of EPR.

Materials and Methods: 38 patients (23 females and 15 males), who underwent EPR for non-neoplastic conditions were identified from a prospectively kept database of all patient seen at the Royal Orthopaedic Hospital Oncology Service. The indications for replacement included failed joint replacement, fracture non-union, failed internal fixation and periprosthetic fractures.

The 38 procedures were identified from September 1995 to June 2007 and included 17 distal femoral replacements, 12 proximal femoral replacements, 4 proximal humeral replacements, 2 distal humeral replacements, 2 hemi-pelvic replacements and 1 total femoral replacement. EPR survivorship was calculated using a Kaplan-Meier survival curve. The quality of patients’ mobility and performance of activities of daily living was used to assess functional outcome.

Results: Patients had a mean age of 60 years (range 15–85 years) at surgery and had between 0 and 4 previous operations prior to EPR. Seven out of 38 patients had recorded deep infection prior to surgery (18%). The Kaplan-Meier implant survival was 91.3% at 5 years, 68.5% at 10 years and 45.7% at 20 years. The limb salvage survival for all reconstructions was 75% at 10 years.

87.4% of patients who underwent a lower limb EPR achieved a satisfactory or very satisfactory functional outcome. 100% of patients achieved a satisfactory or very satisfactory functional outcome in the upper limb EPR group.

3 implants failed, 2 as a result of infection and required staged revisions, 1 eventually requiring amputation, and 1 failed as a result of aseptic loosening. 2 patients dislocated their proximal femoral replacements, both were treated successfully by closed reduction. Despite the salvage surgery subsequent amputation was only required in one patient.

Conclusion: EPR appears to be effective and the medium term survival is encouraging. The aim of a pain free functional limb is achievable with this technique. The complication rates are acceptable considering the salvage nature of these patients. We recommend referral of complex cases to a tertiary centre with expertise in this type of surgery.

Aim: To review treatment outcomes in patients with sacral chordoma treated at our centre over the past 20 years.

Methods: Retrospective review of prospectively kept data. Previously treated patients were excluded. The surgical objective was to obtain clear margins. If sacrifice of S2,3,4 was necessary, this was usually combined with colostomy.

Results: 30 patients were treated (20 males, 10 females), median age 63.5 (28 to 94). Median duration of symptoms before presentation was 79 weeks (3–260), mean tumour size 11 cm. Most had neurological symptoms. Eight tumours involved the S2 roots, 1 the entire sacrum. Treatment was palliative in 7 patients, resection in 23. Operation time averaged 4.5 hours (1.5 to 8). Margins were wide in 7, marginal in 12, and intralesional in 4 patients. There was a high rate of postoperative complications, mostly wound problems (61% of patients). In 1 case this resulted in septicaemia and post-operative death. Average operative blood loss was 1600ml (0–3500). 65% of patients were incontinent of urine and/or faeces. Local recurrence (LR) occurred in 52% of operated patients at a median of 32 months (4–134). Incidence of LR was 60% after intralesional, 57% after marginal and 25% after wide surgery (p=0.49). LR was treated with re-excision, radiofrequency ablation, radio- and occasionally chemotherapy. Overall survival (Kaplan-Meier) of all patients was 57% at 5, and 40% at 10 years. Of operated patients this was 67% and 47%. There was a trend for better survival after wide resection margin. Metastatic disease only occurred in 3 patients.

Conclusion: Chordoma of the sacrum is frequently diagnosed late. Resection is associated with a high complication rate. Local recurrence is the most common cause of death. Early referral to a specialist centre is recommended to optimize treatment. The role of adjuvant therapy remains unclear.

Introduction: Modular tumour prosthetic replacement is especially useful in the region of proximal femur following pathological fractures and failed fixation. The aim of the study was to assess the clinical and functional outcomes following modular tumour prosthesis reconstruction of the proximal femur in 100 consecutive patients with metastatic tumours and to assess its cost effectiveness.

Methods: The study was a retrospective review of 100 consecutive patients who underwent modular tumour prosthetic reconstruction of the proximal femur using the METS prosthesis [Stanmore Implants Worldwide] for metastatic tumours from 2001 to 2008.

Results and conclusion: There were 45 male and 55 female patients. The mean age was 60.2 years. The indications were metastasis [23renal ca, 28 breast ca, 11 ca bronchus, 5 ca prostate and 31 others]. 75 patients presented with pathological fracture or with failed fixation and 25 patients were at a high risk of developing fracture. The mean follow up was 24.6 months [range0–74]. Three patients died within 2 weeks following surgery. Of the 60 patients who were dead 58 did not need revision surgery indicating that the implant provided single definitive treatment which outlived the patient. 1 patient had revision surgery. There were 2 dislocations. 6 patients had deep infections. The implant survival was 98% with revision or amputation as end point. The hospital cost of an endoprosthetic replacement is estimated to be £12,000. This procedure becomes cost effective when compared with no treatment if the patients’ life expectancy is more than 40 days and when compared with internal fixation if the patients’ life expectancy is more than 2 years.

We conclude that METS modular tumour prosthesis for proximal femur provides versatility; low implant related complications and acceptable function lasting the lifetime of the patients with metastatic tumours of the proximal femur providing a cost effective solution.

Introduction: The aim of this study was to investigate the results of a series of cases from a single institution with respect to local disease control and patient survival to determine prognostic factors.

Methods: Electronic patient records were reviewed on all patients with STS between February 1963 and January 2007. 2445 patients had over 30 types of STS. 1639 (67%) had not received any treatment prior to presentation, however, 770 patients (32%) had undergone a previous attempted excision. Survival analyses were done using Kaplan Meier and Cox regression analyses, however, for prognostic factor analysis, only patients presenting without prior treatment were included.

Results: Common diagnoses were liposarcoma (292 patients, 12%), synovial sarcoma (242 patients, 10%) and leiomyosarcoma (239 patients, 10%). Most presented in the thigh (950 patients, 39%), arm (325 patients, 13%) or lower leg (275 patients, 11%) and most were deep to fascia (1581 patients, 74%). The mean size was 10.2cm.

Overall cumulative patient survival was 58% at 5 years and 44% at 10 years. Locally recurrent disease occurred in 350 patients (14%), 204 patients (8%) presented with and 720 patients (30%) subsequently developed metastatic disease.

Prognostic factors for locally recurrent disease were arm tumours (p=0.003, HR=0.3), hip tumours (p=0.01, HR=0.31), thigh tumours (p=0.002, HR=0.52), intralesional margins (p< 0.0001, HR=3.7), high grade tumours (p=0.03, HR=1.8), tumour size 3–6cm (p=0.04, HR=0.54) and tumour size 6–10cm (p=0.03, HR=0.63).

Prognostic factors for patient survival were deep location (p=0.02, HR=1.6), high grade tumours (p< 0.0001, HR=4.7), intermediate grade tumours (p< 0.0001, HR=3.4), surgical margins (p=0.04), age at diagnosis (p< 0.0001, HR=1.02), size of tumour < 3cms (p=0.04, HR=0.29), 3–6cms (p< 0.0001, HR=0.41), 6–10cms (p=0.007, HR=0.63), no locally recurrent disease (p=0.0001, HR=0.59).

Conclusions: Significant prognostic factors have been proven for STS, and marginal margins have not been proven to alter the risk of locally recurrent disease or patient survival.

We have investigated whether improvements in design have altered outcome for patients undergoing endoprosthetic replacement of the distal femur following tumour resection.

Survival of the implant and ‘servicing’ procedures has been documented using a prospective database and review of the implant design records and case records.

A total of 335 patients underwent a distal femoral replacement with 162 having a fixed hinge design and 173 a rotating hinge. The median age of the patients was 24 years (range 13–82yrs). With a minimum follow up of 5 years and a maximum of 30 years, 192 patients remain alive with a median follow up of 11 years. The risk of revision for any reason was 17% at 5 years, 33% at 10 years and 58% at 20 years. Aseptic loosening was the most common reason for revision in the fixed hinge knees whilst infection and stem fracture were the most common reason in the rotating hinges. The risk of revision for aseptic loosening in the fixed hinges was 35% at ten years but appears to have been abolished by the use of a the rotating hinge knee with a hydroxyapatite collar. The overall risk of revision for any reason was halved by use of the rotating hinge.

Improvements in design of distal femoral replacements have significantly decreased the risk of revision surgery but infection remains a serious problem for all patients. We believe that a cemented, rotating hinge prosthesis with a hydroxyapatite collar offers the best chance of long term prosthesis survival.

Introduction: Surgical management of metastatic lesions of the femur reduce pain and improve mobility. Reconstruction for periacetabular metastatic lesions presents a surgical challenge.

Methods: Results of reconstruction of the ileum for supra-acetabular metastatic destruction using antegrade pins and cemented acetabular components are presented. From 1998 to 2005, 25 patients underwent acetabular reconstruction. Age range: 44 to 83 years, mean of 65 years. The most common diagnosis was breast carcinoma (n=10).

Results: Surgery reduced analgesia requirement and improved mobility. There was one revision, two pin breakages and one loose pin removed. The remaining patients have not required revision of the reconstruction.

Discussion: Acetabular reconstruction offers an effective and long lasting method of relieving pain and restoring mobility in patients with metastatic disease. Patient selection requires close liaison with oncologists and consideration must be given to life expectancy of the individual.

Aim: To identify tumour and treatment factors significant for both local control and survival for patients with chondrosarcoma of the pelvis.

Method: The features of all patients with non metastatic chondrosarcoma of the pelvis treated at a tertiary treatment centre between 1971 and 2001 with more than 2 years of follow-up were analyzed.

Results: There were 106 patients with a median age of 44. There were equal numbers of male and female patients in the group. The median size of the tumours was 12cm. 47 tumours were grade 1, 37 were grade 2 and 22 were grade 3. Treatment involved hindquarter amputation in 33 and excision with or without reconstruction in 73. Clear margins (wide or better) were achieved in 34 cases. The excision was marginal in 30 cases and intralesional or contaminated in 37. Local recurrence arose in 39 patients and was related to adequate margins of excision (p=0.03) and grade (p=0.01). Overall survival was 72% at 5 years, 56% at 10 years and 46% at 15 years. Survival was strongly related to grade (p=0.08) but survival beyond 5 years was most strongly related to the adequacy of the excision margins.

Conclusion: Tumour grade is the most important prognostic factor for chondrosarcoma of the pelvis but the ability to obtain clear margins of excision influences both local control and the prospects for long term survival.

Synovial sarcoma is a morphologically well-defined neoplasm that most commonly occurs in soft tissue accounting for 5% to 10 % of all soft tissue sarcomas. We reviewed 156 patients with synovial sarcoma of soft tissues treated at a supra-regional centre to determine survival and prognostic factors.

There were 77men and 79 women with mean age at presentation of 38 years (3 to 84). Follow-up periods ranged from 3 to 494 months (median 43 months). Tumor was located in lower extremities in 111patients, upper extremities in 34 patients, and trunk and pelvis in 11 patients. Overall survival was 66% at 5 years and 48% at 10 years. The 5 and 10 year survival for the 23 patients who had metastases at the time of diagnosis was 13% and 0% respectively compared to 75% and 54% for those without metastases at diagnosis. Local recurrence occurred in 18 patients (13%). The significant prognostic factors for survival included presence of metastases at diagnosis and development of local recurrence. Tumour size and depth, age of patients and use of chemotherapy did not significantly influence survival.

We conclude that the clinical factors which influence survival of patients with synovial sarcoma are different from those of soft tissue sarcomas in general. Biological factors may better predict prognostic survival than the usual clinical factors.

Aim: To identify patient, tumour or treatment factors that influence outcome in patients with radiation induced sarcoma of bone.

Method: A retrospective review of an oncology database supplemented by referral back to original records.

Results: We identified 42 patients who presented to our Unit over a 25 year period with a new sarcoma of bone following previous radiotherapy. The age of the patients at presentation ranged from 10 to 84 years of age (mean: 17 years) and the time interval from previous radiotherapy ranged from 4 to 50 years (median: 14 yrs; mean: 17 years). The median dose of radiotherapy given had been 50 Gy but there was no correlation of radiation dose with time to development of sarcoma. The pelvis was the most common site for development of sarcoma (14 cases) but breast cancer was the most common primary tumour (8 cases). 9 of the patients had metastases at the time of diagnosis of the sarcoma. Osteosacoma was the most common diagnosis (30). Treatment was by surgery and chemotherapy when indicated and 30 of the patients had treatment with curative intent. The survival rate was 41% at 5 years for those treated with curative intent but in those treated palliatively median survival was only 6 months and all had died by one year. The only factor found to be significant for survival was the ability to completely resect the tumour, thus limb sarcomas had a better prognosis (66% survival at 5 years) than central ones (12%)(p=0.009).

Conclusion: Radiation induced sarcoma is a rare complication of radiotherapy. Both surgical and oncological treatment is likely to be compromised by previous treatment the patient has received. Despite this 40% of patients will survive more than 5 years with aggressive modern treatment.

Purpose: To study the results of treatment of symptomatic non-union with endoprosthesis at the Royal Orthopaedic Hospital

Methods: Between 1987 & 2005, 17patients were treated with massive endoprosthesis for non-union. We performed a retrospective review of these case notes

Results: Mean age at diagnosis was 63years (range 36–86). Location of non-union was distal femur in 9, proximal femur in 4, proximal humerus in 2, proximal tibia in 1, distal humerus in 1. The majority of the patients had received prior multiple operations before endoprosthetic surgery.

Four patients had obvious infection confirmed by histology and/or microbiology prior to surgery. Endoprosthetic Reconstruction was performed as a 1 stage procedure in 13 and as a 2 stage in 4.

Complications occurred in 5 patients. These included recurrence of infection in 1, persistent pain in 1, aseptic loosening in 1, periprosthetic fracture in 1 and a non ST myocardial infarction in 1. At the last follow-up, (mean 5years, range 1–18years) majority of patients achieved good range of motion and good mobility.

Conclusion: We conclude that endoprosthetic replacement is a reasonable option for treatment of end-stage non-union in carefully selected patients. Adequate mobility and function can be achieved in majority of patients following such treatment

Purpose of the study: To analyze survival and prognostic factors in a series of patients treated for chondrosarcoma of the pelvis.

Material and methods: The series included 106 patients (53 women and 53 men) treated for non-metastatic chondrosarcoma of the pelvis. Minimum follow-up was two years. Mean age at diagnosis was 44 years. Tumors were grade 1 (n=47), grade 2 (n=37), grade 3 (n=22). Conservative surgery was performed in 73 patients (resection with or without reconstruction) and interilio-abdominal disarticulation for 33.

Results: Resection margins were sufficient for 34 patients (wide or radical resection), marginal for 35, and intratumoral or malignant for 37. Local recurrence was noted in 39 patients (37%). Prognostic factors affecting local recurrence were: quality of resection (p=0.03), grade (p=0.01). Overall survival at 5, 10 and 15 years were 72, 56, and 46% respectively. Survival was strongly correlated with grade (p=0.08) and survival after five years was also correlated with resection margins.

Conclusions: In this series, tumor grade was the most important prognostic factor for patients with chondrosarcoma of the pelvis but achieving satisfactory resection with wide margins also has a significant effect on prognosis for local recurrence and long-term survival.

Background: Limb preserving surgery in patients with tumours involving the whole femur present a formidable challenge.

Results: We present our experience of treating such patients with total femur endoprostheses over the last 30 years (1975 to 2005). There were twenty six consecutive patients including 14 males and 12 females. Average age was 40 years (14 – 82 years) at the time of surgery. Eleven patients were still alive of which nine were free of disease at the time of review. The mean follow-up was 57 months (3 to 348). Using Kaplan Meier estimates, the long-term patient survival at 10 years was 37%. The survival of patients with primary localised tumour was 50% at 10 years.

Revision of the prostheses was necessary in two patients at 110 and 274 months after surgery because of recurrent dislocation in one and aseptic loosening of the acetabular cup and tibial stem in the other. Amputation was necessary in two patients, one due to deep infection and the other due to local recurrence. The long-term limb survival being 92% at 10 years. Nine patients who were alive with no evidence of disease were assessed for function of the salvaged limbs using the musculoskeletal tumour society (MSTS) rating system. The mean functional score was 72%.

Conclusion: We conclude that total femur endoprosthetic replacement offers an excellent method of limb reconstruction following excision of the whole femur either for primary or metastatic tumours. However, patients survival after such operation is poor due to disease related factors.

We have investigated whether improvements in design have altered outcome for patients undergoing endoprosthetic replacement of the distal femur following tumour resection.

Survival of the implant and ‘servicing’ procedures has been documented using a prospective database and review of the implant design records and case records.

A total of 335 patients underwent a distal femoral replacement with 162 having a fixed hinge design and 173 a rotating hinge. The median age of the patients was 24 years (range 13–82yrs). With a minimum follow up of 5 years and a maximum of 30 years, 192 patients remain alive with a median follow up of 11 years. The risk of revision for any reason was 17% at 5 years, 34% at 10 years and 58% at 20 years. Aseptic loosening was the most common reason for revision in the fixed hinge knees whilst infection and stem fracture were the most common reason in the rotating hinges. The risk of revision for aseptic loosening in the fixed hinges was 32% at ten years compared with 4% for rotating hinge knees with a hydroxyapatite collar. The overall risk of revision for any reason was halved by use of the rotating hinge.

Conclusion: Improvements in design of distal femoral replacements have significantly decreased the risk of revision surgery. Infection remains a serious problem for these patients.

Aim: To investigate the outcome of prosthetic pelvic replacements., analyzing complications and suggesting ways of avoiding these

Method: We reviewed the records of all 52 patients undergoing custom made hemipelvic replacement of the pelvis at our centre over the past 30 years.

Results: The mean age of the patients was 40 (range 13 to 75) and the most common diagnosis was chondrosarcoma followed by Ewing’s sarcoma. 4 patients had metastases at the time if diagnosis. All tumours involved the acetabulum (P2) and 9 had a significant extension up into the ilium with 28 involving the pubis. There was a very high incidence of complications – local recurrence arose in 40% and infection in 32% at 5rs, there was a 10% risk of amputation (all for local recurrence). The overall survival of the patients was 69% at 5yrs and 59% at 10 yrs and the survival of the prosthesis without a major complication (infection or local recurrence) was only 40% at 5 and 10 yrs. Local recurrence was related to effectiveness of chemotherapy and margins whilst infection was increased by tumours involving the pubic area.

Discussion: Although a successful hemipelvic replacement can produce a good functional outcome, the incidence of complications is very high. Steps to reduce these risks should be carefully considered including the use of wider margins and the use of silver coated prostheses as well as greater use of local or free flaps in selected cases.

99 patients with new diagnosed soft tissue sarcomas involving the pelvic region were studied to determine the outcome and prognostic factors for survival and local recurrence.

The mean age at diagnosis was 57 years. There were 55 males and 44 females. The mean tumor size was 12cm. The tumor was deep in 79 patients and superficial in 20. Surgical treatment was excision in 93 patients and hindquarter amputation in 6 patients. Histological grade was low grade in 23 and high grade in 75 patients. 7% of the patients had metastases at presentation.

The 5 year overall survival was 57% and local recurrence occurred in 22% of the patients. The risk of inadequate surgical margins in patients with tumors within the pelvic brim was 50% compared to 18% for those with tumors located outside the pelvic brim. The significant predictors of local recurrence were inadequate margins and location of the tumor within the pelvic brim. Tumor size, grade and depth did not influence development of local recurrence. Significant predictors of survival included metastases at presentation, tumor grade and depth. The cumulative 5 year survival for patients with deep high grade tumors, deep low grade tumors, superficial high grade and superficial low grade tumors were 45%, 74%, 63% and 100% respectively (p=0.01). The 5-year overall survival was 66% in those patients without local recurrence compared to 37% in those who develop local recurrence (p=0.005). Multivariate analysis revealed that development of local recurrence was the most important determinant of overall and metastases free survival.

We conclude that patients with pelvic soft tissue sarcoma who develop local recurrence have an extremely poor prognosis. Patients with high grade and inadequate surgical margins represent a particular group with very high risk of metastases and death even with radiotherapy and perhaps should be considered for other adjuvant treatment.

130 consecutive patients with metastastic tumours of the extremity bones treated with resection with or without major endoprosthetic reconstruction were studied retrospectively to determine the indication for surgery, complications, clinical outcome and oncological results of treatment.

The mean age at diagnosis was 61 (22 – 84). The tumours originated from a variety of organs. Lower extremity was involved in 104 and upper extremity in 26. Metastatic disease was solitary in 55 patients and multiple in 75 at the time of surgery. The median follow-up possible from the time of operation to review was 48 months (0-103).

The indication for surgery was radical treatment of solitary metastases with curative intent in 33, pathological fracture in 46, impending fracture in 27, failure of prior fixation devices in 17, painful swelling or extremity in 37. Surgical treatment included excision of expendable bones without reconstruction in 20 patients and resection with endoprosthetic reconstruction in 110 patients. 7 patients received adjuvant chemotherapy and the majority received adjuvant radiotherapy.

At the time of review, 58 patients had died at a mean time of 23 months (0–90) from surgery (53 from progressive metastatic disease and 5 from other causes). 72 were alive at mean follow-up of 22 months (1–103) from surgery. 36 patients (28%) were alive at 2 years post-surgery and 8 (6%) at 5 years. One patient died intra-operatively. Post-operative complications occurred in 32 patients (25%). 18 patients required further surgical procedures for dislocation, infection haematoma, stiff joint, plastic surgical procedures. All the patients had control of pain and 90% achieved desired mobility.

There was no difference in the survival of patients who presented with solitary and multiple metastases, renal and non-renal metastases, and upper or lower limb metastases.

Conclusion: Selected patients with bone metastases can benefit from resection and major bone reconstruction with acceptable morbidity. We have not identified predictable prognostic factors in these selected patients.

Only 1% of all primary bone tumours are situated in the distal humerus. Destruction of the distal humerus by tumour is rare and reconstruction of the distal humerus is challenging. Because of the amount of bone loss following tumour excision, excision arthroplasty or arthrodesis is impossible and hence some form of reconstruction is usually required. Allograft reconstruction and hemiarthroplasty are uncommon and lead to an unpredictable outcome.

Ten patients underwent endoprosthetic replacement of the distal humerus for bone tumours over a thirty one-year period. There were 8 primary and 2 secondary tumours and male to female ratio was 2:3. Average age of the patients was 47.5 years (15–76 years). Mean follow up was 8 years (9 months - 31 years). Four patients required further surgery, three having revision for asceptic loosening and two of these and one other later needing a rebushing. There were no permanent nerve palsies, infections, local recurrences or mechanical failures of the implant. Four patients died of their disease between 12 and 71 months after operation, all with their prosthesis working normally.

Average flexion deformity was 15 degrees (0–35) and average flexion of these patients was 115 degrees (110–135). The average TES Score for these patients was 73% (29% to 93%). The activities which the patients found to be no problem (TES score more than 4.5 out of 5) were: brushing hair, drinking from a glass, putting on make up or shaving, picking up small items, turning a key in a lock, doing light household chores and socialising with friends, whilst activities that proved difficult (TES score less than 3 out of 5) were: gardening and lifting a box to an overhead shelf. Pain was not a problem and only 1 of the surviving patients reported ever having to use regular analgesics.

Conclusions: Endoprosthetic replacement of the distal humerus and elbow joint is a satisfactory method of dealing with these unusual tumours in the long term.

The unusual phenomenon of histological grade change in locally recurrent soft tissue sarcomas is examined by retrospective review of a large sarcoma database. Increased histological grade was found to occur in 20% of recurrent tumours. Several possible factors predisposing to grade change were examined, and only the histologic diagnosis of myxoid malignant fibrous histiocytoma was found to be significant. Despite increased histologic grade, these tumours do not appear to have a worse prognosis in terms of developing systemic disease.

Soft tissue sarcomas (STS) have a reported local recurrence rate of between five and thirty percent. Recurrent tumours are often similar histologically to the initial tumour, however they are occasionally of higher histological grade than the original lesion. Factors that predispose to this change in grade are not known.

We sought to identify the frequency at which locally recurrent STS demonstrate a change in histological grade, and to investigate the possible factors leading to this change. We also investigate whether a change in grade is associated with a poorer prognosis.

We identified one hundred and seventy-three patients who developed locally recurrent STS, one hundred and twenty-four of which met inclusion criteria and who will form the basis of this study. Ninety-two patients (74%) had no change in histological grade, twenty-four (19%) demonstrated an increase in histological grade and eight (7%) a decreased histological grade. Univariate analysis of time to local recurrence, histological diagnosis and use of radiotherapy and chemotherapy did not reveal significant differences between the groups who did and did not undergo change in grade. When the diagnosis of myxoid MFH was looked at separately, there was a higher proportion in the group that developed increased histological grade. Development of a change in grade was not associated with a poorer survival rate.

Increase in histological grade occurs in approximately 20% of locally recurrent STS, but this phenomenon is not associated with a poorer prognosis than if the grade remains the same. A histological diagnosis of myxoid MFH predicts for an increase in histological grade.

Non-union of long bone fractures can be a challenging problem. There are several methods of treatment and they depend upon various patient factors, biology of non-union, and presence of infection. When faced with failure of treatment with biological reconstructive procedures patients have little choice. At our institute we have treated 10 such patients with radical excision and reconstruction using tumour endoprostheses as a last attempt to save the limb.

Median age of the patients was 71 years (25–85). 2 patients were male and 8 were female. Median follow-up was 49 months (8–229). 5 had infected non-union. Resection and massive endoprosthetic reconstruction involved the distal femur in 4 patients, proximal femur 3, distal humerus 2 and total Humerus in 1 patient. Time from diagnosis of non-union to treatment was 0 to 96 months (median 11 months) and patients had had 0 to 6 (median 3) previous operations 5 infected non-unions were operated as 2 stage procedures and received long term antibiotics. 4 out of 5 infected non-unions were salvaged. There were 5 complications, namely periprosthetic fracture, infection, a dislocated shoulder, radial nerve palsy, suture of bosing.

All the patients achieved immediate mobility and stability. Extendible prosthesis allowed partial correction of limb shortening.

Conclusion: Resection of established non-union and reconstruction with endoprostheses is a good salvage operation for elderly and low demand patients in whom time consuming biological reconstruction is not desirable.

Pathological fracture occurs in 5–10% of all primary malignant bone tumours. It is thought that they unfavourably influence survival, because the fracture haema-toma may contaminate adjacent tissues. Management is often more aggressive and one is less inclined to consider limb saving surgery.

Aim of this study was to determine whether the presence of pathological fracture had an effect on rate of limb salvage surgery, role of adjuvant treatment and survival.

A retrospective study was done on all patients with a pathological fracture through localised Ewing’s sarcoma, treated between 1979 and 2001. Of 289 patients with localised Ewing’s sarcoma, 27 had a pathological fracture. Eighteen presented with fracture, in 9 fracture occurred after biopsy. All were treated with chemotherapy according to protocol. Two fractures were already treated by osteosynthesis elsewhere, the rest healed with conservative treatment. After chemotherapy, 20 patients were treated surgically: 19 with limb saving surgery, 1 with amputation. Apart from chemotherapy, treatment was surgery alone in 15, surgery and radiotherapy in 5, and radiotherapy alone in 7 patients. Indications for radiotherapy were close margins, poor chemotherapy response, or pelvic tumours. Surgical margins were wide in 16 patients, marginal in 2, and intralesional in 1 patient. Local recurrence occurred in 2 patients, primarily treated with chemotherapy and radiotherapy alone. Five year survival was 60%, metastasis free survival 59%, both comparable with rates reported in literature.

Conclusion: Chemotherapy allows fractures to consolidate with conservative treatment. Adequate surgical margins can be achieved in the majority of patients with limb saving surgery. Adjuvant radiotherapy does not seem necessary if margins are wide. Survival is not negatively influenced by pathological fracture. The survival rate following limb saving surgery in these patients is similar to that of patients in literature where amputation is done. Limb saving surgery seems a safe option.

Peri- and sub-prosthetic fractures, or pathological fractures below an existing well-fixed femoral component, with or without an ipsilateral knee replacement, present a difficult surgical challenge.

We describe a simple solution, in which a custom-made prosthesis with a cylindrical design is cemented proximally to the stem of an existing, well-fixed femoral component. This effectively treats the fracture without sacrificing the good hip. We describe five patients with a mean age of 73 years (60 to 81) and a mean follow-up of 47 months (6 to 108).

The mean overlap of the prosthesis over the femoral component was 7.5 cm (5.5 to 10). There have been no mechanical failures, no new infections and no re-operations. We suggest that in highly selected cases, in which conventional fixation is not feasible, this technique offers a durable option and avoids the morbidity of a total femoral replacement.

Aim: To identify prognostic for patients who develop local recurrence after initial attempted curative treatment for a soft tissue sarcoma (STS).

Method: All patients who developed a local recurrence (LR) after initial primary treatment of a STS were identified from a prospective database. Their management and outcome were analysed to find prognostic factors.

Results: 178 patients were identified. They had a median age at original diagnosis of 53 and 102 of the patients had high grade tumours, 50 intermediate grade and 23 low grade. The median time to LR was 14 months but extended up to 11.5 years. 47 of the patients developed metastases either before or synchronously with the LR. In these patients the median survival was 20 months with only 4% surviving to 5 years. In the 131 patients who did not have identifiable metastases at the time of diagnosis, 74 subsequently developed metastases at a median time of 12 months following the development of LR.

The median survival for patients without metastases at the time of LR was 3 years with a 31% survival at 10 years. The most important prognostic factor in this group was grade with low grade tumours having a much better outlook (70% survival at 10 years) than intermediate or high grade tumours (24% at 10 years). Complete control of the first local recurrence could not be shown to be a prognostic factor.

Conclusion: Local recurrence has a poor prognosis but this is because it frequently arises in patients who have other bad prognostic factors. Whilst obtaining local control is important, overall survival is poor, but not as bad for those patients who develop metastases.

Aims: To establish the frequency and demographics of soft tissue sarcomas (STS) presenting in the lower limb.

Methods: Patients presenting to a tertiary referral orthopaedic oncology unit over a 10-year period were prospectively entered into a computerised database. The site of primary STS and demographic details were also recorded.

Results: 1519 STS in all body regions were treated. 1067 (70.2%) within the lower limb. 57.0% thigh, 13.0% calf, 8.2% foot and ankle, 7.7% buttock, 5.7% knee, 4.6% pelvis and 3.8% in the groin. There was a male predominance (56.2%). M:F ratio was 2.5:1 for the groin and 1.3:1 for the thigh with the other body regions approximately equal.

Conclusion: The majority of STS are found in the lower limb. In this large series there was a male predominance most marked in groin presentations.

Aims: Soft tissue sarcomas (STS) of the foot and ankle are rare tumours. The aims of this study were to examine the presenting features and highlight those associated with a delay in diagnosis.

Methods: Patients presenting during a 10-year period were identified using a computerised database within the Orthopaedic Oncology Unit at the Royal Orthopaedic Hospital, Birmingham, UK. Additional information was obtained from a systematic case note review.

Results: 1519 patients were treated for STS of which 87 (8.2%) had tumours sited in the foot and ankle. Of these, 75 (86.2%) had presented with a discrete lump (42 (56%) of them having an inadvertent “whoops” excision biopsy), 3 (3.4%) with ulceration and the remaining 9 (10.3%) with symptoms more commonly associated with other benign foot and ankle pathology. Within the group of 9 patients they had previously been treated as plantar fasciitis (3), tarsal tunnel syndrome (2), Morton’s neuroma (1) and none specific hind foot pain (3). Median delay from onset of symptoms to diagnosis as STS was 26 months for this group (mean 50; range 6–180 months) compared to 12 months (mean 32; range 3–240) for the “whoops” biopsy group and 10 months (mean 16; range 2–60 months) for the unbiopsied discrete lump group.

Conclusion: Soft tissue sarcoma in the foot and ankle may present insidiously and with symptoms of other benign pathologies. Failure to respond to initial treatment of suspected common benign pathology should be promptly investigated with further imaging e.g. MRI scan or high resolution ultrasound, or with specialist consultation.

Purpose: To identify the risk of metastases at the time of diagnosis in patients with soft tissue sarcomas and to estimate the cost effectiveness of identifying these.

Methods: A retrospective database review was used to identify all new soft tissue sarcoma patients referred to our unit and to find those identified to have metastases at diagnosis. Data of tumour size, depth, grade, age, type of tumours, Chest x-ray (CXR)/CT chest results were available in all patients. We estimated the efficacy of CXR in identifying metastases and the costs of various staging strategies.

Patients: 1170 with newly diagnosed STS in 7.5 years (1996–2004) were included.

Results: The incidence of metastases at diagnosis was 10% (116 patients), 8.25% (96 patients) had lung metastases and 20 had metastases elsewhere. The risk of having lung metastases at diagnosis was 11.8% in high grade tumours, 6.95% in intermediate grade and 1.2% in low grade tumours. The risk increased almost linearly with size at presentation and was higher in deep tumours and older patients. CXR alone detected 2/3 of all lung metastases. The positive predictive value of the CXR was 93.7%, the negative predictive value was 96.7%, the sensitivity 62.5% and the specificity 99.6%.

The accuracy was 96.9%. CT overestimated metastases in 4%.

Discussion: We recommend that all patients with a newly diagnosed STS should have a CXR and only those with an abnormality or who have large, deep high grade tumours should have a CT chest. This strategy will save £7500 per 100 new patients with STS and will detect 93% of all chest metastases, missing 1 patient with metastases per 166 patients.

Limb preserving surgery following segmental resection of the distal end of the radius and its articular surface presents a major challenge. We have studied 11 consecutive patients with aggressive tumours located in the distal radius that required segmental resection of the distal radius and its articular surface to evaluate the clinical and functional outcome of reconstruction of such defects.

The mean age at the time of diagnosis was 33 years (7–60). Follow up ranged from 12 to 306 months (median 56). Histological diagnosis was osteosarcoma in 4 patients, chondrosarcoma in 2, giant cell tumour in 5 and meta-static carcinoma in 1 patient. Four patients received chemotherapy. The length of excised bone ranged from 6 to 14cm. Reconstruction was performed with non-vascularised proximal fibula strut graft in 6 patients, ulna transposition in 3 and custom made endoprosthesis in 2 patients. The wrist joint was arthrodesed in 5 patients.

At the time of review 2 patients had died of disease, one was alive with disease and 8 were alive and free of disease. Non-union of the graft occurred in one patient, reflex sympathetic dystrophy in 2 and prosthetic dislocation in one. One patient had local recurrence. Four patients required further surgery including one patient who needed an amputation for severe reflex sympathetic dystrophy, one graft revision for non-union, one secondary wrist arthrodesis and one closed reduction of dislocated endoprosthesis. Patients without arthrodesis often had clinical and radiological signs of wrist instability. The majority of the patients achieved satisfactory function with little or no discomfort and ability to perform activities of daily living.

We conclude that limb salvage surgery is worthwhile in patients with resectable tumours of the distal radius.

Myxoid liposarcoma (MLS) is an unusual type of soft tissue sarcoma as it tends to metastasize frequently to sites other than the lungs. This study was aimed to investigate the natural history of patients with MLS to try and identify prognostic factors which could help predict outcome and aid earlier detection of metastases.

Data was prospectively collected from patient notes and analysed retrospectively. Prognostic factors and metastatic pattern were examined using Kaplan-Meier curves. There were 124 patients with MLS, aged between 28 and 93, the median size of the tumours was 12cm and the most common site was the thigh. Following treatment with excision and radiotherapy the 5yr survival was 65%. Survival was related to younger age (p=0.010) and proximal site (p=0.003) and was also related to the % round cell component of the tumour but was not related to either size or depth of the tumour. Site and margins of excision were significant prognostic factors for local recurrence of disease. 32% of patients developed metastases, of whom 18 cases (46.2%) developed pulmonary metastases and 21 (53.8%) developed extra pulmonary metastases. The sites of these varied hugely and was not significantly related to the site or size of the primary tumour. There was no difference in time to develop metastases or in overall survival between the two groups. Median survival following metastases was 24 months.

Although MLS has an unusual pattern of metastases the site of metastases does not predict a better or worse outcome. Intensive follow up for extraskeletal metastases is probably not justified until they become symptomatic.

Large benign lytic lesions of the proximal femur present a significant risk of pathological fractures. We report our experience of treating 9 consecutive patients with such defects treated with curettage and fibula strut grafting without supplementary osteosynthesis to evaluate the outcome of this type of reconstruction..

The mean age at the time of diagnosis was 13 years (8–21). Follow up ranged from 2 to 215 months (median 15). Histological diagnosis was fibrous dysplasia in 10 patients and unicameral cyst in 2. All the patients were at risk of pathological fracture. None of the patients developed pathological fracture after surgery and the lesions consolidated fully within one year. Local recurrence occurred in one patient (8%). Minor donor site complications occurred four patients.

All the patients were able to fully weight usually within 3 months of surgery.

At the time of review all but one patient were completely asymptomatic and fully weight bearing. The only symptomatic patient was the patient with local recurrence which has recently been treated.

We conclude that fibula strut graft is a good method of reconstruction of cystic defects in the proximal femut. It prevents pathological fracture, allows mechanical reinforcement of the lesion and delivers biological tissue allowing early consolidation of the defect.

Introduction and Aims: Endoprosthetic replacement (EPR) following Bone Tumor excision is common. A major complication is infection with serious consequences. The aim is to investigate the cause of infection, management and sequalae.

Method: Over 11, 000 patients have been treated in our unit over 35 years. Information collected prospectively on a database, includes demographic data, diagnosis, treatment (including adjuvant), complications, and outcomes. Data was analysed to identify any infection in EPRs, its management and outcome. Factors such as operating time, blood loss, adjuvant therapy, type of prosthesis were investigated. Outcomes of treatment options were evaluated.

Results: Data was analysed on 1265 patients undergoing EPR over 34 years. Giving a total follow-up time of over 6500 patient years. One hundred and thirty-seven (10.8%) patients had deep infection (defined by a positive culture [n=128] or a clinically infected prosthesis with pus in the EPR cavity [n=9]). Forty-nine (34%) required amputations for uncontrollable infection. The commonest organisms were Coagulase Negative Staphylococcus, Staphylococcus aureus and Group D Streptococci. The only satisfactory limb salvaging operation was two-stage revision, with a 71% success in curing infection. Systemic antibiotics, antibiotic cement or beads and surgical debridement had little chance of curing infection. Infection rates were highest in tibial (23.1%) and pelvic (22.9%) EPRs (p< 0.0001). Patients who had pre- or post-operative radiotherapy had significantly higher rates of infection (p< 0.0001), as did patients with extendable EPRs (p=0.007). Patients who had subsequently undergone patella resurfacing and rebushing also had a higher rate of infection (p= 0.019 & p=0.052).

Conclusion: Infection is a serious complication of EPRs. Treatment is difficult and prolonged. Two-stage revision is the only reliable method for limb salvage following deep infection. Prevention must be the key to reducing the incidence of this serious complication.

Purpose: The purpose of this work was to analyse follow-up and prognostic factors in a series of patients treated for soft tissue tumours as a function of the type of facility providing initial care: a supra-regional referral centre (Royal Orthopaedic Hospital, Birmingham), and 38 regional hospitals in the referral area.

Material and methods: This series included 260 patients (111 women and 149 men) treated between 1994 and 1996. Mean age at diagnosis was 61 years. Primary care was given to 96 patients (37%) in the referral centre and 164 (63%) in other centres. Minimum follow-up was five years. The risk of local recurrence and survival prognosis were studied by risk factor: grade, localisation (supra versus infra aponeurotic), tumour size, quality of resection margins.

Results: High-grade tumours were found in 73% of patients with a supra-aponeurotic localisation in 59%. Mean tumour size was 8.6 cm. Tumours in patients treated in the referral centre were larger (10.3 cm versus 7.5 cm) (p< 0.05). Frequency of local recurrence was 20% for the referral centre versus 37% for the other centres. Overall five-year survival rate was 58% and was correlated with grade, tumour size, and localisation (p< à.05). Overall survival of patients given primary care in the referral centre was not statistically different from those treated in the other centres, but for high-grade tumours (UICC grade III), five-year survival was 41% for the referral centre and 14% for the other centres (p< 0.05).

Discussion: Soft tissue sarcomas are rare tumours. For high-grade sarcomas, the rate of recurrence after treatment and the survival rate were better for patients given primary care in the referral centre. The question of centralising patients with this type of disease in referral centres is raised.

Aims: Tumours of the distal humerus are rare but a challenge to treat. Options for treatment are excision and flail elbow, arthrodesis with considerable shortening, allograft replacement or endoprosthetic replacement (EPR). A retrospective analysis of 10 cases of EPR distal humerus was done to assess their success in treating tumours.

Methods: A retrospective analysis of 10 distal humeral tumours operated between 1970 and 2001 was done by retrieving data from notes. No patient was lost to follow up. The Toronto Extremity Salvage Score (TESS) was used to assess function in patients still alive.

Results: There were 4 male and 6 female patients, with ages ranging from 15 to 76 years. The period of follow up ranged from 5 months to 31 years. 8 patients had primary tumours and 2 had secondary tumours. 4 out of 10 patients died of metastatic disease 12 to 71 months after operation. None of the 10 patients had local recurrence, infection, amputation or permanent nerve palsy. There were 3 revisions at 48, 56 and 366 months for aseptic loosening. There were 3 rebushings of the plastic inserts at 62,78 and 113 months. Two of the three rebushings were done after revision of the humeral component at 6 months and 30 months. The average TESS Score for these patients was 72.91 out of 100 (29.2 to 93.33).

Conclusion: Custom-made EPR for distal humeral tumours are an effective way of replacing the diseased bone leading to a reasonable level of function and an acceptable failure rate.

We reviewed our experience with diaphyseal endoprostheses to determine the survival of this type of reconstruction and factors affecting that survival.

Method: We retrospectively studied 44 patients who underwent endoprostheticreconstruction of diaphyseal bone defects after excision of primary sarcomas between 1979 and 2002 with more than 2 years follow up.

Results: There were 27 males and 17 females, the median age at diagnosis was 25 years (8–75) and the median bone defect was 18cm (10–27.6).There were 33 femoral reconstructions, 6 tibial and 5 humeral. The cumulative overall survival for all patients was 67% at 10 years and prosthetic reconstruction using revision surgery as an end point was 62% at 10 years. The cumulative risk offailure of reconstruction including; infection, fracture, aseptic loosening, local recurrence and amputation was 45% at 10 years but for amputation only was 13% at 10 years. The patient age, the type of prosthesis ;whether cemented oruncemented, site of defect (femur, tibia, and humerus) and length of defect did not influence prosthetic survival.

Conclusion: We concluded that the use endoprostheses for reconstruction of diaphyseal bone defects remains a valuable method of reconstruction with predictable results and compares favourably with other forms of reconstruction of massive diaphyseal bone defects.

Purpose: To see if current guidelines for the early diagnosis of sarcomas can be improved.

Method: Data on 1100 patients referred to our unit with a lump suspicious of sarcoma was analyzed to try and identify clinical features more common in malignant than benign lumps. The following five items were analysed: size, history of increasing size, presence of pain, depth, age. For each of these items sensitivity, specificity, accuracy and weights of evidence were collected. ROC curves were used to identify the most sensitive cut off for continuous data.

Results: The best cut off predicting malignancy for size was 8cm and for age 53 years

The weights of evidence (WE) are logs of the likelihood ratios and can be added and a probability then calculated. e.g. a 36 yr old with a 10cm, deep, painless lump that is increasing in size scores −0.39 + 0.4 + 0.4 – 0.11 + 0.58 = 0.88. This equates to a risk of the lump being malignant of 70%.

Conclusion: This analysis shows that increase in size is the strongest predictor of malignancy/benignancy followed by age > 53 and size > 8cm. This data can help formulate strategies for earlier detection of soft tissue sarcomas.

Introduction: A ‘whoops’ procedure is when a lump, which subsequently turns out to be a soft tissue sarcoma (STS), is shelled out by a surgeon who is not aware of the diagnosis. In many cases residual tumour will be left behind necessitating further surgery. The significance of a whoops procedure in terms of survival and local control remains uncertain. This study has used case matched controls to compare outcome between two groups.

Method: 794 patients of soft tissue sarcoma with minimum follow up of 5 years were found on our prospectively collected database. 113 were whoops cases, 96 had restaging and reexcision. An observer blinded to the outcome of patients matched the whoops cases with virgins by known prognostic factors i.e. grade, depth, patient age, site, size and diagnosis of the tumour. We have investigated outcome in terms of local control, metastatic disease and survival by known prognostic factors and by their status at presentation.

Results: 96 patients with a whoops procedure were compared with 96 referred directly to our unit. Despite attempts to match patients with as many variables as possible there was a tendency for the patients with whoops to have smaller tumours that were subcutaneous, they were however well matched for grade and stage at diagnosis. 64% of whoops patients had adequate final margin whereas only 44% of virgins had adequate margins. Overall 1.43 additional operations were needed to achieve final margins for whoops cases as against 0.21% for virgin cases. Overall 27% patients had amputation 20% for whoops and 34% for virgin cases nearly 60% were ray amputations of foot or hand. Overall 50% had radiotherapy and 25% had chemotherapy. There was no statistical difference in local recurrence or survival of patients between whoops and virgins at 5 years follow up. Inadequate margins and residual tumour were significant risk factors for local recurrence and high grade, size more than 5 cm, and age more than 50 years were significant prognostic factors for overall survival of the patients.

Conclusion: Inadvertent surgical excision of a STS is not desirable but does not seem to lead to an adverse outcome in this series in which wide re-excision of the area involved has been carried out.

Purpose; To show that Distal Femoral Endoprosthetic Replacement for metastatic disease can be performed with relatively few complications and allows good pain control and mobilisation for otherwise severely compromised patients.

Method; This is a retrospective study, using the oncology database, patient records and local correspondence, looking at 23 patients with distal femoral metastases who had limb salvage with a Distal Femoral Endoprosthesis (DF EPR).

Results; There were 10 males (43%) and 13 females (57%), mean age 65 (38–84). 13 (57%) had Renal, 6 (26%) Breast and 5 other primaries identified. Five had additional metastases. 8 (35%) had pathological fractures. The mean time for diagnosis of mets was 67 months ranging from 0 (i.e. at the time of primary tumour) to 30 years since the original diagnosis. 15 patients had surgery alone. 3 patients were lost to follow up. 15 patients have diseased at a mean of 26 months (4–58) post op. There was one intra-op and four post-op complications. The majority of the patients were satisfied post op with regards to pain and mobility.

The generally unfavourable prognosis and perceived risks have led surgeons to palliate, stabilise in situ or amputate for distal femoral metastases despite recognised morbidity and life style restrictions. We conclude that DF EPR should be considered as a limb salvage option in patients with distal femoral mets.

Metastatic bone disease resulting in acetabular destruction can provide the orthopaedic surgeon with the difficult challenge of achieving a stable reconstruction of the hip to provide pain relief and restoration of mobility.

We review of twenty patients with metastatic disease requiring major acetabular reconstruction presenting to our orthopaedic oncology unit over a five year period was undertaken. This yielded 15 female and 5 male patients with mean age 59 years. The primary lesion was breast (8 cases), renal (3) prostate (2), myeloma (2) and others (5) with a solitary acetabular metastasis in 75% of cases. Eight patients had received radiotherapy to the region pre-operatively.

In all cases, diseased bone was macroscopically cleared from the pelvis and reconstruction performed by means of a Harrington procedure with threaded pins passed antegrade from the iliac crest 915 cases) or mesh and screws (5 cases), all reinforced with cement around which a total hip arthroplasty was performed.

Mean follow-up was 16 months. Complications were broken pin (1 case), dislocation of femoral prosthesis (1) and deep venous thrombosis (1). Three patients died of their disease at a mean of 12 months from surgery. The remaining 17 patients continue to function at a satisfactory level with no patients having required revision surgery for loosening or deep infection.

We believe that surgical reconstruction of the acetabulum is worthwhile and can provide these deserving patients with improvement in quality of life.

130 consecutive patients with metastatic tumours of the extremity bones treated with resection with or without major endoprosthetic reconstruction were studied retrospectively to determine the indication for surgery, complications, clinical outcome and oncological results of treatment.

The mean age at diagnosis was 61 (22 – 84). The tumours originated from a variety of organs. Lower extremity was involved in 104 and upper extremity in 26. Metastatic disease was solitary in 55 patients and multiple in 75 at the time of surgery. The median follow-up possible from the time of operation to review was 18 months (0–103)

The indication for surgery was radical treatment of solitary metastases with curative intent in 33, pathological fracture in 46, impending fracture in 27, failure of prior fixation devices in 17, painful swelling or extremity in 37. Surgical treatment included excision of expendable bones without reconstruction in 20 patients and resection with endoprosthetic reconstruction in 110 patients. 7 patients received adjuvant chemotherapy and the majority received adjuvant radiotherapy.

At the time of review, 58 patients had died at a mean time of 23 months (0–90) from surgery (53 from progressive metastatic disease and 5 from other causes). 72 were alive at mean follow-up of 22 months (1–103) from surgery. 36 patients (28%) were alive at 2 years post-surgery and 8 (6%) at 5 years. One patient died intra-operatively. Post-operative complications occurred in 32 patients (25%). 18 patients required further surgical procedures for dislocation, infection haematoma, stiff joint, plastic surgical procedures. All the patients had control of pain and 90% achieved desired mobility.

There was no difference in the survival of patients who presented with solitary and multiple metastases, renal and non-renal metastases, and upper or lower limb metastases.

We conclude that selected patients with bone metastases can benefit from resection and major bone reconstruction with acceptable morbidity. We have not identified predictable prognostic factors in these selected patients.

Aims: Tumours of the distal humerus are rare but a challenge to treat. Options for treatment are excision and ßail elbow, arthrodesis with considerable shortening, allograft replacement or endoprosthetic replacement (EPR). A retrospective analysis of 10 cases of EPR distal humerus was done to assess their success in treating tumours.

Methods: A retrospective analysis of 10 distal humeral tumours operated between 1970 and 2001 was done by retrieving data from notes. No patient was lost to follow up. The Toronto Extremity Salvage Score (TESS) was used to assess function in patients still alive.

Results: There were 4 male and 6 female patients, with ages ranging from 15 to 76 years. The period of follow up ranged from 5 months to 31 years. 8 patients had primary tumours and 2 had secondary tumours. 4 out of 10 patients died of metastatic disease 12 to 71 months after operation. None of the 10 patients had local recurrence, infection, amputation or nerve palsy. There were 3 revisions at 48, 56 and 366 months for aseptic loosening. There were 3 rebushings of the plastic inserts at 62,78 and 113 months. Two of the three rebushings were done after revision of the humeral component at 6 months and 30 months. The average TESS Score for these patients was 72.91 out of 100 (29.2 to 93.33).

Conclusion: Custom-made EPR for distal humeral tumours are an effective way of replacing the diseased bone leading to a reasonable level of function and an acceptable failure rate.

Introduction: Many soft tissue sarcomas undergo initial inadequate excision (the Whoops! procedure) and are then referred to specialist services. The outcome of 108 such patients is presented.

Method: Records of 108 patients were traced from the prospectively collected database at our institute who had reexcisions of soft tissue sarcomas. We investigated outcome both in terms of local control and overall survival following treatment to assess the significance of an inadequate initial excision.

Results: Over a ten-year time period we was 887 new patients with soft tissue sarcoma of whom 140 patients (11%) presented following previous inadequate excision. Of these, 108 patients underwent re-excision in an attempt to achieve clear margins. 80% tumours were high grade and 40% were deep. After reexcision, 57% patients were found to have residual tumour. 32% patients had close margins after re-excision. Over all survival of patients was 80% at 5 years and local recurrence rate was 10%. Local recurrence of patients with marginal excision was 15% at 5 years but for clear margins was 6.7%. Of 108 patients 22 (20%) had metastasis at 5 years of which 16.6% were in the lung. 81% of metastasis occurred in patients with close margins of reexcisions. Survival of patients with close margins was worse than wide margins (p = 0.0025).

Conclusion: Local recurrence was statistically associated with grade, depth, margins of re excision and presence of residual tumour. Overall survival was influenced by close margins and residual tumour but not by local recurrence. Re-excision of soft tissue sarcoma to clear margins improves survival of the patients at 5 years.

Purpose: The purpose of this work was to analyse survival and prognostic factors in a series of patients treated for pelvic chondrosarcoma.

Material and methods: This series included 67 patients (27 women and 40 men) treated between 1971 and 1996 for pelvic chondrosarcoma. Mean age at diagnosis was 45 years (range 18–78). Forty percent of the tumours were grade I. The most frequent localisation was the iliac bone. Conservative surgery was performed in 45 patients. The only surgical treatment possible in 22 patients was an inter-ilioabdominal disarticulation. Resection margins were adequate for only 19 patients (wide resection). Marginal resection was noted in 14 patients with intra-tumour resection in 17.

Results: Overall 5- and 8-year survival was 65% and 58% respectively. Local recurrence rate was 40%, occurring a mean 27 months after initial surgery. Statistical analysis did not reveal any correlation between tumour size, tumour grade, type of surgery, resection margin, and local recurrence. Results were nevertheless less favourable in case of inadequate surgical margins. Tumour grade, tumour size, patient age, gender, and quality of resection did not have a significant effect on overall survival. Local recurrence was the only negative factor predictive of survival (p< 0.05).

Discussion: Development of local recurrence appears to be the most important negative predictive factor in patients with pelvic chondrosarcoma. In this localisation, satisfactory resection margins are often difficult to achieve. Most authors propose inter-ilioabdominal disarticulation as a last resort procedure. The question of the indication for more aggressive initial surgery to obtain more radical resection margins remains open.

Purpose: Primary bone tumours situated at the distal end of the humerus are exceptional and observed in only 1% of the cases. Reconstruction at this level is often difficult due to the wide bone resection. Choosing a massive prosthesis is an interesting method allowing correct carcinological and functional results. We report a series of ten patients who underwent reconstruction of the lower end of the humerus between 1970 and 2001 with a massive prosthesis after tumour resection.

Material and methods: This series included four men and six women, mean age 51 years (15–76). Eight patients had primary bone tumours and two had secondary bone lesions. Mean follow-up was 79 months (9–372). The custom-made constrained hinge prosthesis composed of chromium-cobalt and titanium was cemented. Regular clinical and radiological follow-up data were recorded. The Henneking score and the Toronto Extremity Survival Score (TESS) were used to assess functional outcome.

Results: Three patients underwent revision for aseptic loosening of the humeral component at 48, 56 and 366 months with problem of polyethylene insert wear for two of them. There were no infctions or local recurrences and no secondary amputations. The posterior or anterolateral approach was used for humeral resection (mean 153 mm, 63–160 mm). Postoperatively, three patients developed transient palsy (one radial and two ulnar) which regressed. Four patients died from metastasis and had a satsifactory prosthesis result at time of death. The mean TESS was 73% (29–93%) at last follow-up

Discussion: Although this is a small series, the long-term results appear to indicate that reconstruction of the lower extremity of the humerus with a massive prosthesis is a satisfactory option for this rare tumour localisation.

Aim: The purpose of this retrospective study was to analyse the risk factors, causes, bacteriology of deep infection following extensible endoprosthetic replacement for bone tumours in children and to review our experience in the treatment of 20 patients with infected prostheses.

Materials and methods: 123 patients with extensible endoprostheses were treated between 1983 and 1998. Three types of prostheses, which differed in the lengthening mechanism used, were implanted. 20 of these were diagnosed to have deep infection. Patients were divided into 3 groups: group I- 5 patients were treated with a single stage revision, group II- 13 patients were treated with a two stage revision procedure, group III- 2 patients had a primary amputation. Control of infection was assessed clinically and with inflammatory markers. Function was assessed using the MSTS score.

Results: The overall incidence of infection was 16%. The incidence of infection at the proximal tibia and distal femur was 27% and 14% respectively. Staphylococcus epidermi-dis was the most common organism. The most common clinical features were pain and swelling around the pros-theses. Infection in most cases was immediately preceded by an operative procedure or by distant a focus of infection. The number of operative procedures and the site of the prosthesis were significant risk factors. The success rate was 20% in Group I and 84.6% Group II. Amputation was the salvage procedure of choice for failed revision procedures. The mean MSTS functional score was 83% in patients in whom the infection was controlled.

Conclusion: The incidence of deep infection is high following extensible endoprostheses. The site of the pros-thesis and the number of operative procedures are significant risk factors.

Endoprosthetic replacement (EPR) following Bone Tumour excision is common. A major complication of EPRs is infection, which can have disastrous consequences.

This paper investigates the cause of infection, management and sequelae.

Over 10, 000 patients have been treated in our unit over 34 years. Information collected prospectively on a database includes demographic data, diagnosis, treatment (including adjuvant), complications, and outcomes. Data was analysed to identify any infection in EPRs, its management and outcome. Factors such as operating time, blood loss, adjuvant therapy, type of prosthesis (extendable or standard) were investigated. Outcomes of treatment options were evaluated. Data was analysed on 1265 patients undergoing EPR over 34 years, giving a total follow up time of over 6500 patient years.

137 (10.8%) patients have been diagnosed with deep infection (defined by a positive culture [n=128] or a clinically infected prosthesis with pus in the EPR cavity [n=9]). Of these 49 (34%) required amputations for uncontrollable infection. The commonest organisms were Coagulase Negative Staphylococcus, Staphylococcus aureus and Group D Streptococci. The only satisfactory limb salvaging operation was 2 stage revision, which had 71% success in curing infection. Systemic antibiotics, antibiotic cement or beads and surgical debridement had little chance of curing infection. Infection rates were highest in the Tibial (23.1%) & Pelvic (22.9%) EPRs (p< 0.0001). Patients who had pre or post-operative radiotherapy had significantly higher rates of infection (p< 0.0001), as did patients with extendable EPRs (p=0.007).

Patients who had subsequently undergone patella resurfacing and rebushing also had a higher rate of infection (p=0.019 and p=0.052). Infection is a serious complication of EPRs. Treatment is difficult and prolonged. 2 stage revision is the only reliable method for limb salvage following deep infection. Prevention must be the key to reducing the incidence of this serious complication.